A fellow classmate of mine, Guapita, and I are riding with my preceptor, Angel and her partner for a day shift in ******** City. We get a call for an unconscious person at a bus stop at suchandsuch street. Guapita and I are riding in the back of the Medic unit and we don't see anything until we arrive and jump out.
I'm greeted by the sight of several firefighters, bystanders and drunks surrounding a bench at a bus stop. Sitting on this bench is a man who's doubled over at the waist with drool and blood dribbling out of his mouth. Angel and I go up and pull him upright.
He's a big fellow. About 6ft 2in (2 meters) and about 175lbs (about 80kg). He's got pinpoint pupils, extremely slow breathing and is almost unresponsive to almost any stimulus. These symptoms combined with the neighborhood and bystanders leads me to suspect heroin as the culprit. A glance at Angel tells me she's thinking the same thing.
The guy's not so unresponsive that he can't be hauled up into the ambulance with some help from a firefighter and I. Once in the stretcher, he proceeds to snore away at a rate of 8 breaths per minute. I look at his arms: no track marks but he has beautiful veins. Angel is already preparing a dose of Narcan.
Narcan is the brand name of a drug called naloxone. It's defined as a competitive antagonist antidote for opiate overdose. In plain language, it knocks opium, heroin or morphine out of the opiate receptors in the brain and immediately reverses a opiate-based overdose. It also puts the chronic heroin user into immediate withdrawal. I notice that this guy's got big arms and shoulders. He's almost as tall as me and is pretty well built. I'm thinking that the last thing I want is for this guy to go into withdrawal in the back of my Medic unit.
Angel hands me a syringe with 0.12 mg of Narcan and a nasal atomizer. "We'll try a dose in the schnozz before we get a vein." She says. At this point, Guapita, acting as my second, has started oxygen at 12 Liters per minute via non-rebreather mask. I gently rest my knee just above this guy's knees and my other leg is barring his Left arm. His right arm is under a cot strap.
In goes the Narcan, on goes the O2 mask. "Gurgle, snort, gurgle. ..." No change in respirations or mental state. This guy also has not a single obvious track or needle mark on his body. I'm thinking he snorts his hey-ron and that might have an effect on this nasal administration.
By this time Angel's partner has prepared all the stuff to start and IV and hands me an alcohol prep. Guapita shifts around and sits on the guy's thighs and I trap the guys left arm under my armpit to give me a stable site for an IV and be ready for when he freaks out.
Pop! Perfect IV. 16 gauge in the left antecubital fossa. (the hollow of the elbow where a big vein is) and a saline lock (a small tube for the administration of medications without having to hang a bag of fluid). Angel hands me a syringe of 0.4mg of Narcan. In it goes, followed by about 10cc of saline to flush it into his system.
Needles into the sharps containers and we're tense. We're all ready for this guy to explode in a whirling fit of stinky, spitting fury at us for having taking his high for which he probably paid a lot of money.
He sits up.
He looks around.
"Hey! Woah! Thank you very much!" He nods around to each of us. "You guys are great! I really appreciate what you do."
Everyone else in the back of the Medic unit looks as dumbfounded as I feel.
"Hey, man, I feel great! Can I go home now?"
Posted by --maddog at 18:56
I was working my part-time job as a Park Ranger. As I patrolled a nearby lake park, I came across a neighbor, MS, on his bike.
"Have you seen Mr. Neighborofmine?" he asked me. "His wife's worried about him. He headed out for a run 3 hours ago and she's worried about him"
I don't blame her. The temperature is approaching 100 degrees Farenheit and the humidity is about 98 percent. Mr. Neighborofmine is 70 years old and has 2 prosthetic legs below the knees. I've seen him out running every day.
I agree to keep an eye out for him and I cruise along, stopping to ask each person I see if they've seen Mr. Neighborofmine. A couple people have but not for about 30 minutes. At one point, I'm standing on the path, asking another stroller. I'm situated directly behind Mr. Neigbhorofmine's house. MS's house is the one next door. They both back onto the path that goes around the lake in this park.
As I'm speaking to a person on the path, I hear MS hollering for me. I look up the hill toward the house and see him rushing towards the back porch. I also see a lump on the back porch dressed in running clothes.
In my bicycle saddlebags, I have a first aid kit, gloves and a mask for rescue breathing. I run up the hill, dragging my bicycle behind me. On my way I leave a trail of gear as I discard my riding gloves, helmet, sunglasses and, finally, bicycle.
Mr. Neighborofmine is lying on his side on the concrete porch. He's blue and grey. His hands are blue and his face is blue and dusky grey. I perform a sternal rub. No response. I check pusle and breathing. None.
Training takes over. MS is a little frantic and is trying to remember CPR. "I've got the CPR. Call 9-1-1." I say.
"I've got them on the phone." Says a new voice. The neighbor from the other side, HW, has shown up and has a cordless phone in her hand."They want to give you CPR instructions."
"Tell them I'm an EMT, here's my number." I rattle it off and she conveys it to the Dispatcher. Good enough. Time to get to work. I put on my gloves and assemble the CPR mask. It's got a one-way valve and a filter to keep me from getting a mouthful of patient. I get his head positioned and try a couple breaths. Air goes in but I hear a gurgling when I blow in. I see a little bit of chest rise but I also see his stomach rise too. Damn! Am I putting air in his stomach? His belly falls as he exhales. Hm.
I move to his chest to perform chest compressions and find my landmarks are a little off. His chest seems to stick up a lot. I ask if he's had heart problems before. Trying to get a history from somebody. The answer comes back "no" and then I have an "AHA!" moment. I remember seeing Mr. Neighborofmine many times when he was out running. His back is curved forward and slightly hunched over. I've seen it referred to as Kyphosis of the spine. It can create a challenge when maintaining an airway and such while the patient is on his back.
I start chest compressions and feel/hear the crackling noise as his ribs separate from his sternum. Ugh! I always hate that. I roll through my chest compressions and back to breathing. Again, I'm having trouble getting good air in the lungs. MS is flapping around trying to both be helpful and not get in the way.
"Put your fingers like this." I say and show him how to position his thumb and finger to press on the crichoid cartilage. (This is a process where pressing on the hard cartilage of the windpipe causes it to push down and close off the soft and floppy esophagus. This allows more air to go into the lungs and helps keep whatever's in the stomach from coming back up.)
"Like this?" he does it right after a few tries.
"Yes. Now press here, gently. Good."
I try a couple more breaths and they go in much better. Still gurgling but air is getting into the lungs. I continue the cycle of chest compressions and rescue breathing. Sweat is cascading off me. Somewhere in the back of my head I remember that the heat index for the day (what it feels like) is 110 degrees Fahrenheit. I'm feeling it now.
EMS is on the way. I can hear the sirens in the distance. After a few more cycles of CPR, I check for a pulse and realize that the patient is pink. PINK!!! This means that I'm doing CPR correctly! He was blue to begin with, meaning he had very little oxygen left in his tissues. The purpose of CPR is to push oxygen into the lungs where it can dissolve into the blood, and then move it around by pumping on the heart. The fact that Mr. Neighborofmine is now pink means I'm getting oxygen in and moving it around. Right on!
At some point, I look up and see Mrs. Neighborofmine standing behind the sliding glass door. She's been watching everything.
My ambulance and Engine show up. It's all business. AED, Oxygen and BVM, move the patient to a back board and then the stretcher. I'm standing on the lower carriage of the stretcher and continuing chest compressions as we roll around the house and to the ambulance.
Into the rig we go and we roll. We meet the Medic unit en route on a nearby highway. Two medics get on board our ambulance. One starts to set up the EKG/Defribillator while the other sets up to intubate. I'm thinking, "IV access?" Of course, I can't do any of the advanced skills because my jurisdiction won't let volunteers practice ALS skills, regardless of one's certification level.
The medic who is intubating prepares a Miller blade (a laryngoscope blade that is long and flat) that's about 2 sizes too long for this patient and proceeds to dig around in the patient's mouth. He looks like he's stirring soup! The then goes to insert the endotracheal tube (ETT) and I notice he hasn't lubricated it.
He gets the tube in but doesn't secure it. I help him get the stylus out but it's stuck!! He didn't lubricate that, either. I find myself both bagging (pushing air down the intubation tube with a special bag) and holding the tube in place. I call out that I see vapor in the tube as a landmark for proper placement. The medic then checks for lung and gastric sounds as another method.
Still no secured tube. I have doubts about it being properly placed. I hear all kinds of gurgling as I push air down.
The intubating medic then connects a device that will tell him how much CO2 is coming out of the tube each time the patient exhales. This is a very definitive way of knowing whether or not you have it in the right place. A tube in the esophagus will not give out a consistent amount of CO2, whereas a properly placed tube with good air exchange will. This is read by a wave form on the EKG monitor that has a CO2 monitoring device (capnography).
The wave form is tiny, almost too small to read. "Looks good." says the medic.
"I'm still getting a lot of gurgling in this tube. Should we check it again? Maybe suction?" Says I as I turn on the suction unit next to the medic. He says nothing and proceeds to prepare another device to check the tube. This is another CO2 detector that merely changes color in the presence of CO2. We attach it, I breathe for the patient. The color remains the same. I'm thinking at this point the medic's going to re-tube the patient to be sure he's got it.
"Hyperventilate him. Go faster." He says to me.
Still doesn't change. The medic then check the inflatable cuff at the end of the tube. This cuff keeps the tube in place in the trachea and keeps air from leaking out around it or stuff from going into the lungs. It's not properly inflated and won't stay that way (this is done by using a syringe attached to a tiny air tube).
Does he remove the ETT and try again at this point? No. He prepares a dose of epinephrine to inject down the tube.
Meanwhile, the other medic has been fumbling around with the EKG. She reads asystole, or no electrical heart activity, on her monitor. She sets up another set of leads to verify and I though she's going to go into transcutaneous pacing. That's where one uses a regular rhythm of shocks to make the heart muscle flex and move blood around. It can also, at times, cause the heart to take over and beat on its own as blood and oxygen get to the heart muscle.
Does she do that?
Does she start an IV?
Nope. She seems more concerned with verifying the asystole than with doing anything about it. Oh, yeah. she's also doing chest compressions with one hand as she's fooling with the EKG.
I notice, also that my patient, who I made pink with basic CPR, is now blue and ashen. Dammit!
Once we get to the hospital, Someone takes over respirations from me and I'm back to doing chest compressions all the way into the emergency room. People waiting in the hall show their surprise at seeing a 6 foot 4 inch, 245lb bald man soaked with sweat, standing on a stretcher doing chest compressions with the words "PARK RANGER" written across his back. I'm sure I'm quite a sight.
The hospital staff takes over, I pass what information I have about how long Mr. Neighborofmine was down and I get out of the way. I stagger through the main ER towards the refreshment station where I wash my hands and drink about 2 quarts of water.
A few minutes later, I see the hospital staff filter out of Mr. Neighborofmine's room. "We'll call it at 1358." says a doctor. I think I saw that coming. It still sucks. It always sucks. I think when it stops sucking, I need to get a job doing something else.
I phone my boss to let him know that I'm going to be a little over my shift and tell him why. He offers to come pick me up from the hospital and asks me if I'm OK. The crew from my ambulance gives me a ride back to the scene where I expect to find a disaster area. Instead I find MS has gathered up all my stuff and my bike. He's stowed them away in his shed to keep them from getting stolen.
We talk for a bit about the incident and I ask him if he's doing OK. I also make sure he knows he can talk to me or I can put him in touch with people to talk to. He lost 3 family members, including his father and his sister, in as many years. He says as much and says, "I won't say I'm used to it but I got a good handle on it and a good bunch of family." as he rests his hand on his daughter's shoulder.
At my office, where I fill out a huge incident report, everyone is great. My boss gets me another shirt, someone gets me a big, cold bottle of water. They all want to be sure I'm OK. I do a mental/emotional check and find that, yes, I am OK.
On my way home, I stop by the scene again to speak with the other neighbor, HW. She's with her family, preparing dinner. I chat with her and her husband. Her 4 year old son says, "Mr. Neighborofmine wasn't breathing! That's bad! I'm four years old! I'll be 5 soon!" I thank HW for her help and listen to her speak of feeling helpless. I assure her she did great by having the wherewithal to call 9-1-1 right away.
On my way out, I notice that Mrs. Neighborofmine has returned from the hospital with her 2 sons and a good friend. I stop by there to offer my condolences. "I think it hasn't hit me yet. Thank you very much for what you did. You were super. I can't thank you enough." she says to me. She's really touched. Wow.
As I'm pedaling home, I'm sad for the family and friends of Mr. Neighborofmine. I'm happy to be among the living. I'm also reviewing and checking everything I did to be sure I've done it all right. I think I did. I'm pretty confident I did good and I can find no major faults with my performance. I could have been more of an a**hole with the Medics to be sure they did their job right but I have a feeling that would not have ended well.
I also think about the cycle of life and death. I think I'm fortunate to have been a part of this cycle for Mr. & Mrs. Neighborofmine. I could sense that it meant a lot to Mrs. Neighborofmine to see me and speak to me afterwards. It's a situation I'm not often in. Usually I hand the patient off to the hospital and get ready for the next call. Mrs. Neighborofmine got to see that I do care, that I'm not just a stranger who takes her husband away. THAT'S hometown EMS.
I come home to an empty house. Herself is out for the evening for business. Just me and the dog and the cat. Not for long. Word travels fast and, within 90 minutes I've got a house full of friends and family and I'm making spaghetti for 6.
At some point, in the middle of the wine, food and jokes, I look around a the gaggle of people in my house. I vow to enjoy them all while I have them. It's all good.
We the living.
Posted by --maddog at 17:12